Healthcare Provider Details

I. General information

NPI: 1972987055
Provider Name (Legal Business Name): CHILDREN'S DENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 COMMERCIAL DR
BUFFALO MN
55313-1736
US

IV. Provider business mailing address

1004 COMMERCIAL DR
BUFFALO MN
55313-1736
US

V. Phone/Fax

Practice location:
  • Phone: 612-746-1530
  • Fax: 612-746-1531
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SARAH WOVCHA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-746-1530